Commentary: What Repeal and Replace of the ACA could mean for Behavioral Health

We are currently in the midst of one of the most dire public health crisis in our nation’s history. Everyday, 246 people die from suicides and overdoses (CDC 2016, CDC 2016). Approximately 1 in 5 adults aged 18 or older - 43.6 million Americans - experience a mental illness in a year. About half of this number - 21.5 million Americans - have a substance use disorder (NSDUH 2014). This disease burden costs the nation at least $467 billion annually in health care, lost earnings, and public disability payments (Insel 2015).

The new year brings drastic and unprecedented political transitions. Health care reform was a pillar of Donald Trump’s campaign yet his policy proposals, most notably the repeal and replace of the Affordable Care Act, remain largely undefined. Individuals with mental illness and addiction risk losing significant protections following a full or partial repeal of the ACA. Some of the most important protections added by the ACA involve reforms aimed at increasing insurance coverage for behavioral health treatment. In the context of the mental illness and addiction crisis facing our nation, we must seriously consider the following reforms that are currently being discussed -

Elimination of Medicaid Expansion: Medicaid Expansion increased access to insurance for many individuals by allocating federal dollars to help states increase Medicaid eligibility to up to 138% of the federal poverty line. Individuals with mental illness and addiction are more likely than their peers to benefit from this expansion. Furthermore, research shows that Medicaid coverage is associated with greater access to mental health and substance use disorder treatment. One study found that low-income individuals with serious mental illness enrolled in Medicaid were 30% more likely to receive treatment than their non-covered peers. In the 20 states that did not expand Medicaid, 1.9 million uninsured individuals with mental illness or substance use disorders have incomes that qualify them for coverage if their state had expanded Medicaid. This number will expand exponentially if the 30 states and DC that expanded Medicaid lose federal support for this expansion and must decrease eligibility (HHS 2016).

Removal of Essential Health Benefits: The ACA included mental health and addiction coverage as an essential health benefit (EHB) requirement for all non-grandfathered individual and small group plans and Medicaid alternative benefit plans provided through Medicaid expansion. The ACA also requires these health plans to cover behavioral health benefits at parity or at the same level as physical health benefits (health plans in the large group market were already required to do this). Without this protection, health insurers commonly restrict access to behavioral health care. If the EHB requirements were removed, millions of people would no longer have parity within their benefits, threatening access to medically necessary care. While it is highly unlikely that the EHB requirement can be repealed without 60 votes in the Senate, the benefits of this critical protection must be highlighted to ensure that federal legislators understand how catastrophic it would be if individuals could no longer access the mental health and addiction services they need.

Elimination of pre-existing conditions: The ACA prohibits most plans from denying individuals coverage or requiring that individuals pay more because of a pre-existing health condition, including mental illness or substance use disorders. This discriminatory practice was common prior to to implementation of the ACA. If this provision was removed, individuals with behavioral health disorders may be denied coverage or charged more for their health insurance, limiting the accessibility of care.

As we look towards 2017, we must keep in mind what might happen if these ACA protections are eliminated. Without thoughtful and evidence-based replacement solutions, individuals with behavioral health disorders will lose the health insurance coverage that is critical to accessing medically necessary care and reducing the thousands of deaths annually due to mental illness and addiction.